Antimicrobial Stewardship Gap Analysis

How robust is your antimicrobial stewardship program? Take this brief survey to determine the gaps in your stewardship initiatives.

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  • Facility Demographics

    9. Part of Integrated Delivery Network (IDN) or Health System?

    Executive Ownership

    8.

    How many of the following members are represented on your antimicrobial stewardship (AMS) committee?

    • - Infectious disease physician
    • - PharmD with ID background or stewardship training
    • - Microbiology services
    • - Infection prevention staff
    9.

    What is the current participation model of your physician leader responsible for stewardship program outcomes at your facility?

    Staff Development

    10.

    Does your facility have existing programs in place to train staff on antimicrobial stewardship initiatives, including:

    • - Renal dose adjustment
    • - Streamlining principles
    • - C. difficile and MDRO surveillance using NHSN principles
    • - Culture surveillance
  • Information Technology / Tools

    11.

    What is your facility currently using to report interventions?

    12.

    What is your facility currently using for clinical decision support?

    Communication/Inter-department Support

    13.

    How are your core antimicrobial stewardship (AMS) initiatives currently communicated between departments?

    14.

    What percentage of antimicrobial stewardship recommendations are accepted by your physicians?

    IV-to-PO Conversion

    15.

    Does your facility's IV to PO policies include any of the following medications:

    • - quinolones
    • - fluconazole
    • - linezolid
    • - metronidazole
    • - voriconazole
    • - TMP/SMX
    • - clindamycin

    Renal Dosing Adjustment

    16.

    How many medications are included in your facility's renal dosing protocol?

    Targeted Antimicrobial Surveillance

    17.

    Do you have a medical staff policy and procedure that identifies criteria-based antimicrobials and defines criteria for use?

    (Including recommendations for: vancomycin, carbapenems, echinocandins, linezolid, tigecycline, daptomycin, piperacillin-tazobactam)

    Formulary Review

    18.

    When organisms have a MIC that is reported as sensitive but may still result in treatment failure, do you use pharmocokinetics/pharmacodynamics to optimize the dose of vancomycin/aminoglycoside (vanc/AG)?

  • Antibiogram, Culture and Sensitivity Reporting

    19.

    Is your facility antibiogram updated annually and developed in accordance with standards by the Clinical and Laboratory Standards Institute (CLSI)?

    Empiric Antimicrobial Treatment Guidelines

    20.

    Do you have specific treatment recommendations based on national guidelines and local susceptibility to assist with antibiotic selection for common clinical conditions (e.g. CAP, HCAP, VAP, meningitis)? (Including recommendations for: Upper and Lower respiratory, Gastrointestinal, Genitourinary, Skin/Soft Tissue, Bone and Joint, CNS infections)

    21.

    Are your empiric antimicrobial guidelines tailored to a facility-specific antibiogram?

    22.

    Are your empiric guidelines readily available to medical staff at point of prescribing?

    Antimicrobial De-Escalation and Streamlining

    23.

    What percentage of patients/cultures are assessed for de-escalation?

    24.

    Is there a method in place to identify patients with the following:

    • - Antimicrobial agents for a period longer than 48 or 72 hours
    • - Patients with positive culture regardless of presence of antimicrobial order
    • - Time-sensitive automatic stop orders for specified antibiotic prescriptions
    • - Automatic alerts and notifications in situations where therapy might be unnecessarily duplicative

    Metrics

    25.

    Do you have a method in place to capture days of therapy (DOT) per 1000 patient days?

    Documentation and Reporting

    26.

    Do you document and report interventions on antimicrobial stewardship (AMS) to the following clinical groups:

    • - Medical Executive Committee
    • - Pharmacy & Therapeutics
    • - AMS Committee
  • Results

    Thank you for taking the assessment. Your results will be emailed to you shortly.


    Are you interested in resources and guidelines for your antimicrobial stewardship program? Visit our Clinical OneSource portal, to get references, tools and educational webinars specific to antimicrobial stewardship – all provided by our Pharmacy OneSource clinical team.


    Criteria for score:

    Red = Your facility has an antimicrobial stewardship program is in its infancy and could use more optimization.

    Yellow = Your facility has an intermediate antimicrobial stewardship program and should continue to assess and optimize its policies and procedures.

    Green = Your facility has a robust antimicrobial stewardship program and should continue to stay up-to-date with best practices.


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